Cigna Individual Dental Insurance Plans

The Cigna Dental plan works great when using in network providers. It as well has no waiting period if you have previously had a Dental insurance and you transition to this plan in the first 30-days of leaving dental insurance plan (Individual or Group).

With Cigna there is more to smile about.

You get flexible benefits and premium levels to meet your needs and budget, plus:

15%discount on monthly premiums for any additional family members on the plan

Available for all ages, including those 65 and older

No application or processing fees

If you have had dental insurance for more than a year, you may be eligible to waive the waiting period so you won’t have to wait for benefits yo begin

No need to submit claims when you use a Cigna DPPO Advantage Network provider

24/7live customer service at 800.Cigna24

Online access with com. You can view bills and claims online, anytime – and make a payment, too

Mobile access on the Find a dentist, check coverage and show your ID card with the myCigna Mobile App.

You have freedom.

You are free to choose a provider from our large national network or one from outside the network. Keep in mind, you’ll save the most if you visit a Cigna DPPO Advantage Network provider. Find providers in our network at Cigna.com/ifp-providers.

In the chart below, you can see how your savings may be greater when visiting a CignaDPPOAdvantageNetwork

provider with a Cigna Dental 1500 Plan compared with your other options.

Chart A1

PROCEDURE

CLASSCATEGORY

CIGNADPPOADVANTAGENETWORK

OUT-OF-NETWORK

WITHOUTDENTALINSURANCE

Cleaning (Adult Prophy) – D1110

Class I

$0

$44

$88

Filling (2 Surfaces) – D2392

Class II

$26

$150

$210

Crown (Porcelain &

High Noble Metal) – D2750

Class III

$352

$827

$1,084

Orthodontics (Braces) – D8080

Class IV

$2,093

$4,891

$6,302

If you have a different plan, services may not be covered and discounts may vary. Chart is estimated, benefits may vary by provider and location.

Data as of June

Excludes orthodontia benefits. Waiting period may vary by stat Eligibility for waiver of waiting period is on a per person basis.

Estimate based on the national average of a standard Cigna Dental 1500 plan; subject to deductible and coinsurance (as applicable), results in specific states may If you visit an out-of- network provider, you are responsible for the difference in the amount that Cigna reimburses (i.e. MAC) for such services and the amount charged by the dentist.

Dental Terms

Below you will find easy-to-understand definitions for commonly used words.

CignaDPPOAdvantageNetwork: Dentists that have contracted with Cigna and agreed to accept a predetermined contracted fee for the services provided to Cigna customers. Visiting a provider in this network means you’ll save the most money, because the fee is discounted.

Out-of-Network: Providers who have not contracted with Cigna to offer you savings. They charge their own standard fees.

BalanceBilling: When an out-of-network provider bills you for the difference between the charges for a service, and what Cigna will pay for that service after coinsurance and Maximum Allowable Charge (MAC) have been applied. For example, an out-of-network provider may charge $100 to fi a cavity. If MAC is $50 for that service and the coinsurance is 50%, Cigna will pay $25 and you will pay $25. Because you are visiting an out-of-network provider, the provider may bill you the remaining $50; thus your total out-of-pocket cost will be $75. These charges are separate from any applicable deductible and coinsurance.

CalendarYearMaximum: The most your plan will pay during a calendar year (12-month period beginning each January 1). You’ll need to pay 100% out of pocket for any services after you reach your calendar year maximum. This typically applies to Class 1, 2 and 3.

LifetimeMaximum: The most your plan will pay during your lifetime. You’ll need to pay 100% out of pocket for any services after you reach your lifetime maximum. A lifetime maximum typically applies to Class 4 services. (Applicable to Cigna Dental 1500 plan.)

Coinsurance: Your share of the cost of a covered dental service (a percentage amount). You pay coinsurance plus any deductible amount not met yet for that calendar year. For example, if you go to the dentist and your visit costs

$200, the dentist sends a claim to Cigna. If you have already met your annual deductible amount, Cigna may pay 80% ($160) and you will pay a coinsurance of 20% ($40).

CalendarYearDeductible: The dollar amount you must pay each year for eligible dental expenses before the insurance begins paying for basic, major restorative care services and orthodontia, if covered by your plan.

LifetimeDeductible: The dollar amount you must pay once in your lifetime for eligible dental expenses before the insurance plan begins paying for Basic, Major Restorative Care Services and Orthodontia, if covered by your plan.

MaximumAllowableCharge(MAC): The most Cigna will pay a dentist for a covered service or procedure for out-of-network dental care that is based on a basic Cigna DPPO Advantage fee schedule within a specifi area. See example provided under Balance Billing.

StandardFee: The fee that a provider charges to a patient for a service who does not have dental insurance.

If a patient has dental insurance and visits a Cigna DPPO Advantage Network provider, the provider charges the negotiated rate/contracted fee.

Contracted Fee: The fee to be charged for a service that Cigna has negotiated with a contracted provider on your behalf.

DENTALBENEFIT

Cigna Dental 1500 Plan

CIGNADPPOADVANTAGENETWORK

Offers the most savings, 35%1 national average.

OUT-OF-NETWORK

Your out-of-pocket expenses will be higher; these providers have not agreed to offer Cigna customers our contracted or discounted fees. Example provided in chart A1.

You pay the difference between the provider’s standardfee and 50% of the MAC (after separate lifetime deductible)

If you choose to visit a dentist out-of-network, you will pay the out-of-network benefit and the difference in the amount that Cigna reimburses for such services and the amount charged by the dentist, except for emergency services as defined in the policy. This is known as balance billing.

Based upon 01/01/2014 – 12/31/2014 National Average Charges projected by Cigna Dental as of 07/01/2015. Fees vary by

NJ, VT & IL: 6-month waiting period for all classes; WV: 3-month waiting period for all classes; MO & RI: no waiting period for all Classes; You may be eligible to waive the waiting period for Classes II & III if you have continuous 12 months of prior coverage from a valid dental insurance plan. Orthodontia waiting period cannot be w

Bitewings: 1 set in any consecutive 12-month period. Limited to a maximum of 4 films per set

Sealants

1 treatment per tooth per lifetime. Payable on unrestored permanent bicuspid or molar teeth for participants less than age 14

FluorideTreatment

1 per consecutive 12-month period for participants less than age 14

Space Maintainers (non-orthodontic)

Limited to non-orthodontic treatment for prematurely removed or missing teeth for participants less than age 14

CLASSII:BASICRESTORATIVESERVICES

NonroutineX-Rays

Full mouth or Panorex: 1 per consecutive 60-month period

Fillings

1 per tooth per consecutive 12-month period (applies to replacement of identical surface fillings only). No white/tooth colored fillings on bicuspid or molar teeth

Routine Tooth Extraction

Includes an allowance for local anesthesia and routine postoperative care

Emergency Treatment

Paid as a separate benefit only if no other service, except x-rays, is rendered during the visit

CLASS III: MAJOR RESTORATIVE SERVICES

Periodontal (Deep Cleaning)

1 per quadrant per consecutive 36-month period

PeriodontalMaintenance

Payable only if a consecutive 6-month period has passed since the completion of active periodontal surgery. 1 periodontal maintenance or routine prophylaxis procedure per consecutive 6-month period (periodontal maintenance procedure is Class III; routine prophylaxis is Class I)

Crowns

1 per tooth per consecutive 84-month period. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crown or bridges. Replacement must be indicated by major decay. For participants less than age 16, benefits limited to resin or stainless steel

Root Canal Therapy

1 per tooth per lifetime

WisdomToothExtraction

Includes an allowance for local anesthesia and routine postoperative care

Denturesand Partials

1 per arch per consecutive 84-month period

Bridges

1 per consecutive 84-month period. Benefits will be considered for the initial replacement of a necessary functioning natural tooth extracted while the person was covered under this plan

CLASSIV:ORTHODONTIA

This summary contains highlights only.

Whatis not covered by this planExcludedservices

Covered expenses do not include expenses incurred for:

Procedures which are not included in the polic

Procedures which are not necessary and which do not have uniform professional endorsement.

Procedures for which a charge would not have been made in the absence of coverage or for which the covered person is not legally required to

Any procedure, service, supply or appliance, the sole or primary purpose of which relates to the change or maintenance of vertical

Procedures,appliances or restorations whose main purpose is to diagnose or treat dysfunction of the temporomandibular joint (Services are covered in AR, MN, NM, NV, and VT).

The alteration or restoration of

The restoration of teeth which have been damaged by erosion, attrition or

Bite registration or bite

Any procedure, service or supply provided primarily for cosmetic Facings, repairs to facings or replacement of facings on crowns or bridge units on molar teeth shall always be considered cosmetic.

The surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement; any device, index or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments;

removal of an existing implant.

Crowns,inlays, cast restorations, or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite resin filling due to major decay

or fracture.

Corebuild-ups.

Replacement of a partial denture, full denture, or fixed bridge or the addition of teeth to a partial denture unless:

Replacement occurs at least 84 consecutive months after the initial date of insertion of the current full or partial denture; or

The partial denture is less than 84 consecutive months old, and the replacement is needed due to a necessary extraction of an additional functioning natural tooth while the person is covered under this plan (alternate benefits of adding a tooth to an existing appliance may be applied); or

Replacement occurs at least 84 consecutive months after the initial date of insertion of an existing fixed bridge (if the prior bridge is less than 84 consecutive months old, and replacement is needed due to an additional

necessary extraction of a functioning natural tooth while the person is covered under this plan. Benefits will be considered only for the pontic replacing the additionally extracted tooth).

The removal of only a permanent third molar will not qualify an initial or replacement partial denture, full denture or fixed bridge for

The replacement of crowns, cast restoration, inlay, onlay or other laboratory prepared restorations within 84 consecutive months of the date

of insertion.

The replacement of a bridge, crown, cast restoration, inlay, onlay or other laboratory prepared restoration regardless of age unless necessitated by major decay or fracture of the underlying natural

Any replacement of a bridge, crown or denture which is or can be made useable according to common dental

Replacement of a partial denture or full denture which can be made serviceable or is r

Replacement of lost or stolen applianc

Replacement of teeth beyond the normal complement of

Prescription

Any procedure, service, supply or appliance used primarily for the purpose of splinting.

Athletic mouth

My ofunctionalther

Precisionor semi-precision attachmen

Denture duplication

Separatec harges for acid et

Labialveneers (laminate).

Porcelainor acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars.

Preciousor semi-precious metals for crowns, bridges, pontics and abutments; crowns and bridges other than stainless steel or resin for participants under 16 years old.

Chargesfor sterilization of equipment, disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies and infection control.

Chargesfor travel time; transportation costs; or professional advice given on the phone.

Temporary,transitional or interim dental

Anyprocedure, service or supply not reasonably expected to correct the patient’s dental condition for a period of at least three years, as determined by C

Diagnostic casts, diagnostic models orstudy models.

Anycharge for any treatment performed outside of the United States other than for emergency treatment (any benefits for emergency treatment which is performed outside of the United States will be limited to a maximum of $100 per consecutive 12-month period).

Anycharges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facilit

Services that are deemed to be medical

Services for which benefits are not payableaccording to the“General Limitations”section.

General Limitations

No payment will be made for expenses incurred for you or any one of your dependents:

Forservices not specifically listed as covered services in the polic

Forservices or supplies that are not dentally necessar

Forservices received before the effective date of c

Forservices received after coverage under this policy

Forservices for which you have no legal obligation to pay or for which no charge would be made if you did not have dental insurance c

Forprofessional services or supplies received or purchased directly or on your behalf by anyone, including a dentist from any of the following:

Yourself or your emplo

A person who lives in the insured person’s home, or that person’s emplo

A person who is related to the insured person by blood, marriage or adoption, or that person’s emplo

Foror in connection with an Injury arising out of, or in the course of, any employment for wage

or profit.

Foror in connection with a sickness which is covered under any workers’compensation or similar law.

Forcharges made by a hospital owned or operated by or which provides care or performs services for the United States Government, if such charges are directly related to a military-service- connected c

Services or supplies received as a result of dentaldisease, defect or injury due to an act of war, declared or

Tothe extent that payment is unlawful where the person resides when the expenses are incurr

Forcharges which the person is not legally required to

Forcharges which would not have been made if the person had no

To the extent that billed charges exceed the rate of reimbursement as described in the

Forcharges for unnecessary care, treatment or

Tothe extent that you or any of your dependents are in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid.

Foror in connection with experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty

Proceduresthat are a covered expense under any other dental plan which provides dental

Tothe extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault”insurance law or an uninsured motorist insurance law. Cigna will take into account any adjustment option chosen under such part by you

or any one of your dependents.

2016 PLAN IMPORTANT DISCLOSURES

Cigna Dental 1500 Plan includes a combination of insurance coverage and discounted services. The insurance coverage shall be only for the classes of service referred to in The Schedule of a purchased plan. Discounts are not available in Maryland, New York and Virginia.

Dental Plans are insured by Cigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc. Rates may vary based on age, family size, geographic location (residential zip code) and plan design.

All rates are subject to change upon 30 days’prior notice in AK, AL, AR, AZ, CO, CT, DC, DE, HI, IA, ID, IL, IN, KS, KY, MA, ME, MI, MN, MO, MT, ND, NE, NH, NJ, NM, OH, OK, OR, PA, RI, SD, TN, UT, VT, WI and WY, 31 days’prior notice in SC, 40 days’prior notice in MD, 45 days’prior notice in FL and 60 days’prior notice in CA, GA, MS, NV, TX, VA and WV. In LA rates are guaranteed for the initial 12-months of coverage, except if due to addition of a newly covered person, a change in age or geographic location, or a change in policy coverage. Thereafter, rates are subject to change upon 45 days’prior notice. In NC, dental rates are guaranteed for a 12-month period. Dental plans apply waiting periods to covered basic (6-months), major (12-months) and orthodontic (12-months) dental care services. In WV, a 3-month waiting period applies to covered basic, major and orthodontic dental care services. In IL, NJ, and VT, a 6-month waiting period applies to covered major and orthodontic dental care services. Waiting periods do not apply in MO and RI. In OH, a 12-month waiting period applies. Some covered services are determined by age: Topical application of fluoride or sealant, space

maintainers, and materials for crowns and bridges. If the plan covers replacement of teeth, there is no payment for replacement of teeth that are missing prior to coverage. In FL, payment limitation no longer applies after 24 months. In MD, NY and OH, payment limitation no longer applies after 12-months of continuous coverage.

HC-NOT21 et al., VT HC-NOT56 et al., WI HC-NOT54 et al.) have exclusions, limitations, reduction of benefits and terms under which a policy may be continued in force or discontinued.

The policy may be cancelled by Cigna due to failure to pay premium, fraud, ineligibility, when the insured no longer lives in the service area, or if we cease to offer policies of this type or any individual dental plans in this state, in accordance with applicable law. You may cancel the policy, on the first of the month following our receipt of your written notice. We reserve the right to modify this policy, including policy provisions, benefits and coverages, consistent with state or federal law. This individual plan is renewable monthly or quarterly.

For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd, Hartford, CT 06152 or call 866.GET.Cigna (866.438.2446).

The Dental Plans do not include pediatric dental services as required under the federal Patient Protection and Affordable Care Act (PPACA). This coverage is available in the insurance market. Please contact your insurance carrier, agent/producer, or the Health Insurance Marketplace if you wish to purchase PPACA compliant pediatric dental coverage.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, and Cigna Dental Health, Inc. In Texas, the Dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

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